Provider Demographics
NPI:1427194315
Name:HAYWARD, MARK STUART (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STUART
Last Name:HAYWARD
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2137 LAKESIDE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-6808
Mailing Address - Country:US
Mailing Address - Phone:703-852-7278
Mailing Address - Fax:703-859-7644
Practice Address - Street 1:4026 WARDS RD STE G1
Practice Address - Street 2:MEDICAL DEPARTMENT #138
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-0060
Practice Address - Country:US
Practice Address - Phone:703-852-7278
Practice Address - Fax:703-859-7644
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1057265OtherNCCPA (PA-C)
MD154267Y1ZMedicare PIN
MDP00750855Medicare PIN